Dosing limitation for an implantable medical device

ABSTRACT

A method for limiting patient-initiated electrical signal therapy to a cranial nerve of a patient is provided. An electrical signal therapy limit is selected from the group consisting of; a maximum number of patient-initiated signals, a maximum dose of electrical signals, a maximum duration of electrical signal, a maximum rate of change of the number of patient-initiated signals, a maximum rate of change of the dose of electrical signals, and a maximum rate of change of the duration of the electrical signals all per unit of time. If the electrical signal therapy limit is exceeded a therapy is delivered to the cranial nerve selected from the group consisting of; providing therapy, providing reduced therapy, providing enhanced therapy, inhibiting therapy, providing background therapy, and inhibiting background therapy.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates generally to medical devices, and, moreparticularly, to methods, apparatus, and systems for limitingpatient-initiated electrical signal therapy by a medical device.

2. Description of the Related Art

There have been many improvements over the last several decades inmedical treatments for disorders of the nervous system, such as epilepsyand other motor disorders, and abnormal neural discharge disorders. Oneof the more recently available treatments involves the application of anelectrical signal to reduce various symptoms or effects caused by suchneural disorders. For example, electrical signals have been successfullyapplied at strategic locations in the human body to provide variousbenefits, including reducing occurrences of seizures and/or improving orameliorating other conditions. A particular example of such a treatmentregimen involves applying an electrical signal to the vagus nerve of thehuman body to reduce or eliminate epileptic seizures, as described inU.S. Pat. Nos. 4,702,254, 4,867,164, and 5,025,807 to Dr. Jacob Zabara,which are hereby incorporated in this specification in their entirety byreference.

More generally, the endogenous electrical activity (i.e., activityattributable to the natural functioning of the patient's own body) of aneural structure of a patient may be modulated in a variety of ways. Inparticular, the electrical activity may be modulated by exogenouslyapplied (i.e., from a source other than the patient's own body)electrical, chemical, or mechanical signals applied to the neuralstructure. The modulation (hereinafter referred to generally as“neurostimulation” or “neuromodulation”) may involve the induction ofafferent action potentials, efferent action potentials, or both, in theneural structure, and may also involve blocking or interrupting thetransmission of endogenous electrical activity traveling along thenerve. Electrical signal therapy or electrical modulation of a neuralstructure (also known as “electrical signal therapy”) refers to theapplication of an exogenous therapeutic electrical signal (as opposed toa chemical or mechanical signal), to the neural structure. Electricalsignal therapy may be provided by implanting an electrical deviceunderneath the skin of a patient and delivering an electrical signal toa nerve such as a cranial nerve. The electrical signal therapy mayinvolve performing a detection step, with the electrical signal beingdelivered in response to a detected body parameter. This type ofstimulation is generally referred to as “active,” “feedback,” or“triggered” stimulation. Alternatively, the system may operate without adetection system once the patient has been diagnosed with epilepsy (oranother medical condition), and may periodically apply a series ofelectrical pulses to the nerve (e.g., a cranial nerve such as a vagusnerve) intermittently throughout the day, or over another predeterminedtime interval. This type of stimulation is generally referred to as“passive,” “non-feedback,” or “prophylactic,” stimulation. Thestimulation may be applied by an implantable medical device that isimplanted within the patient's body.

Generally, implantable medical devices (IMD) are capable of receiving asignal that may affect the operation of the IMD from an external source,such as a patient-initiated signal or a signal in the patient'senvironment. For example, a patient-initiated signal may be used toactivate a predetermined function of the IMD, such as providingadditional therapeutic electrical signals to a cranial nerve of thepatient. A magnetic sensor may be provided in the IMD to detect asignificant magnetic field, either from the patient or the patient'senvironment (for example an MRI machine) and in response, the IMD mayactivate a predetermined function. A patient-initiated signal such as amagnetic field may be an inhibitory input or an excitatory input. Theinhibitory input may relate to inhibiting a function normally performedby the IMD. For example, application of a first patient-initiatedmagnetic field to the IMD may cause delivery of the electrical signalfrom the IMD to the nerve to be inhibited for a certain time period.Conversely, application of a second patient-initiated magnetic fieldsignal to the IMD may comprise an excitatory input that may prompt theIMD to perform additional functions. For example, additional electricalsignal therapy may be performed by the IMD based upon a secondpatient-initiated magnetic signal input. The magnetic signal input maybe generated by a patient by placing a magnet proximate the skin areaunder which the implantable medical device resides in the human body.Both types of magnetic field signals are typically referred to as“magnet modes” or as “magnet mode” operation. Other types ofpatient-initiated signals, such as a tap signal on the IMD, or aradio-frequency (RF) signal provided to the device, may be used inaddition to magnetic field signals.

One problem associated with the state of the art is that optimal safetyand efficacy of neurostimulation by an IMD may be compromised byallowing a patient to initiate neurostimulation ad libitum. For example,excessive delivery of electrical current to a neurological structure mayresult in a net electrical charge on, and subsequent damage to, thetarget neurological structure. Current doses that do not lead to tissuedamage may lead to discomfort. Also, extra dosing may lead to reducedefficacy by interfering with short-term or long-term recovery periodsnecessary or advisable for proper and/or safe neural functioning.Further, battery life can be shortened by excessive dosing. On the otherhand, blanket prohibition of patient-initiated neurostimulation may leadto ineffective alleviation of symptoms during acute crisis, when extradosing may be helpful, e.g., during an epileptic seizure suffered by apatient having an implanted vagus nerve stimulation (VNS) device. Also,blanket prohibition of patient-initiated neurostimulation, ifcommunicated to the patient, may remove any placebo effect benefit thepatient may receive from signaling the IMD to perform neurostimulationvia the actions of passing the magnet over the IMD or tapping the IMD,among other modes of initiating the therapeutic electrical signal.

The present invention is directed to overcoming, or at least reducing,the effects of one or more of the problems set forth above.

SUMMARY OF THE INVENTION

In one aspect, the present invention provides a method for providing analternative mode of electrical signal therapy provided by an implantablemedical device (IMD) to a cranial nerve of a patient, comprisingspecifying a threshold of an electrical signal parameter; receiving aninput from a patient; determining whether to implement the alternativemode based on said input and said threshold, said alternative modediffering in at least one neurostimulation parameter from a normalstimulation mode; and performing the alternative mode of electricalsignal therapy, in view of the result of the determining step, or notperforming the alternative mode of electrical signal therapy, in view ofthe result of the determining step.

In one aspect, the present invention provides a method for limitingpatient-initiated electrical signal therapy provided by an implantablemedical device (IMD) to a cranial nerve of a patient by specifying atleast one electrical signal therapy limit selected from the groupconsisting of a maximum number of patient-initiated signals to provide atherapeutic electrical signal per a time period, a maximum dose of thetherapeutic electrical signal per a time period, a maximum duration ofthe therapeutic electrical signal per a time period, a maximum rate ofchange of the number of patient-initiated signals to provide atherapeutic electrical signal per a time period, a maximum rate ofchange of the dose of the therapeutic electrical signal per a timeperiod, and a maximum rate of change of the duration of the electricalsignal therapy per a time period; receiving a patient-initiated signalto begin a therapeutic electrical signal; determining whether or notsaid electrical signal therapy limit is exceeded by said step ofdetecting a patient-initiated signal; and performing an action inresponse to said step of determining whether or not said limit isexceeded, said action selected from the group consisting of providing afirst electrical signal therapy to said cranial nerve, providing asecond, reduced electrical signal therapy to said cranial nerve,providing a third, enhanced electrical signal therapy to said cranialnerve, inhibiting an electrical signal therapy to said cranial nerve,providing a background electrical signal to said cranial nerve, andinhibiting a background electrical signal to said cranial nerve.

In another aspect, the present invention provides a method for limitingpatient-initiated electrical signal therapy provided by an implantablemedical device (IMD) to a cranial nerve of a patient by specifying atleast one limit on patient-initiated electrical signal therapy to acranial nerve of a patient; receiving a patient-initiated signal toprovide an electrical signal therapy to a cranial nerve; determiningwhether or not said at least one limit on patient-initiated therapy isexceeded by said step of receiving a patient-initiated signal; providingan electrical signal therapy to said cranial nerve of the patient ifsaid at least one limit is not exceeded by said step of receiving apatient-initiated signal; and not providing an electrical signal therapyto said cranial nerve of the patient if said at least one limit isexceeded by said step of receiving a patient-initiated signal.

In another aspect, the present invention provides a method for limitingpatient-initiated electrical signal therapy provided by an implantablemedical device (IMD) to a cranial nerve of a patient by specifying atleast one limit on patient-initiated electrical signal therapy to acranial nerve of a patient; receiving a patient-initiated signal toprovide an electrical signal therapy to a cranial nerve; determiningwhether or not said at least one limit on patient-initiated therapy isexceeded by said step of receiving a patient-initiated signal; providinga first therapeutic electrical signal to said cranial nerve of thepatient if said at least one limit is not exceeded by said step ofreceiving a patient-initiated signal; and providing a second, reducedtherapeutic electrical signal to said cranial nerve of the patient ifsaid at least one limit is exceeded by said step of receiving apatient-initiated signal.

In one aspect, the present invention provides an implantable medicaldevice (IMD) for providing a therapeutic electrical signal to a cranialnerve of a patient's body, including a sensor to detect apatient-initiated signal to initiate an electrical signal therapy; and acontroller operatively coupled to said sensor, said controller todetermine if said patient-initiated signal to initiate an electricalsignal therapy exceeds a predetermined limit on providing a therapeuticelectrical signal to a cranial nerve of a patient, provide a therapeuticelectrical signal to said cranial nerve if said patient-initiated signaldoes not exceed said predetermined limit, and not provide a therapeuticelectrical signal to said cranial nerve if said patient-initiated signaldoes exceed said predetermined limit.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention may be understood by reference to the followingdescription taken in conjunction with the accompanying drawings, inwhich like reference numerals identify like elements, and in which:

FIGS. 1A-1C provide stylized diagrams of an implantable medical deviceimplanted into a patient's body for providing an electrical signal to aportion of the patient's body, in accordance with one illustrativeembodiment of the present invention;

FIG. 2A illustrates a block diagram depiction of the implantable medicaldevice of FIG. 1, in accordance with one illustrative embodiment of thepresent invention, and FIG. 2B illustrates a block diagram depiction ofthe patient-initiated electrical signal controller shown in FIG. 2A; and

FIG. 3 illustrates a flowchart depiction of a method for performinglimited patient-initiated electrical signal therapy, in accordance withan illustrative embodiment of the present invention.

While the invention is susceptible to various modifications andalternative forms, specific embodiments thereof have been shown by wayof example in the drawings and are herein described in detail. It shouldbe understood, however, that the description herein of specificembodiments is not intended to limit the invention to the particularforms disclosed, but on the contrary, the intention is to cover allmodifications, equivalents, and alternatives falling within the spiritand scope of the invention as defined by the appended claims.

DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS

Illustrative embodiments of the invention are described herein. In theinterest of clarity, not all features of an actual implementation aredescribed in this specification. In the development of any such actualembodiment, numerous implementation-specific decisions must be made toachieve the design-specific goals, which will vary from oneimplementation to another. It will be appreciated that such adevelopment effort, while possibly complex and time-consuming, wouldnevertheless be a routine undertaking for persons of ordinary skill inthe art having the benefit of this disclosure.

Embodiments of the present invention provide for an input to the IMDthat would prompt the IMD to operate in an alternative mode for apredetermined time period, or until another triggering input isreceived. The alternative mode may provide for prompting an alternativeoperation of the IMD, by which is meant a mode other than a primarymode. A primary mode is a preprogrammed mode in which the IMD operatesfor a majority of the time and in which the IMD delivers a majority ofits electrical signal therapy, as represented as the sum of thedelivered doses, to the patient. The alternative mode differs from theprimary mode in at least one neurostimulation parameter.Neurostimulation parameters in which the alternative mode can differfrom the primary mode will be discussed in more detail below. In oneembodiment, the alternative mode is a patient-initiated mode ofoperation. The alternative mode(s) may provide flexibility incontrolling the operation of the IMD.

Although not so limited, a system capable of implementing embodiments ofthe present invention is described below. FIGS. 1A-1C depict a stylizedimplantable medical system 100 for implementing one or more embodimentsof the present invention. FIGS. 1A-1C illustrate an electrical signalgenerator 110 having main body 112 comprising a case or shell 121 (FIG.1B) with a header 116 (FIG. 1A) for connecting to leads 122. Thegenerator 110 is implanted in the patient's chest in a pocket or cavityformed by the implanting surgeon just below the skin (indicated by aline 145, FIG. 1A), similar to the implantation procedure for apacemaker pulse generator.

A stimulating nerve electrode assembly 125, preferably comprising anelectrode pair, is conductively connected to the distal end of aninsulated, electrically conductive lead assembly 122, which preferablycomprises a pair of lead wires (one wire for each electrode of anelectrode pair). Lead assembly 122 is attached at its proximal end toconnectors on the header 116 (FIG. 1B) on case 121. The electrodeassembly 125 may be surgically coupled to a cranial nerve 127 in thepatient's neck or at another location, e.g., near the patient'sdiaphragm. Other cranial nerves may also be used to deliver thetherapeutic electrical signal. The electrode assembly 125 preferablycomprises a bipolar stimulating electrode pair 125-1, 125-2 (FIG. 1C),such as the electrode pair described in U.S. Pat. No. 4,573,481 issuedMar. 4, 1986 to Bullara. Suitable electrode assemblies are availablefrom Cyberonics, Inc., Houston, Tex., USA as the Model 302 electrodeassembly. However, persons of skill in the art will appreciate that manyelectrode designs could be used in the present invention, includingunipolar electrodes. Returning to FIGS. 1A and 1C, the two electrodesare preferably wrapped about the cranial nerve 127, and the electrodeassembly 125 may be secured to the nerve by a spiral anchoring tether128 (FIG. 1C) such as that disclosed in U.S. Pat. No. 4,979,511 issuedDec. 25, 1990 to Reese S. Terry, Jr. and assigned to the same assigneeas the instant application. Lead assembly 122 is secured, whileretaining the ability to flex with movement of the chest and neck, by asuture connection 130 to nearby tissue (FIG. 1C).

In one embodiment, the open helical design of the electrode assembly 125(described in detail in the above-cited Bullara patent), which isself-sizing and flexible, minimizes mechanical trauma to the nerve andallows body fluid interchange with the nerve. The electrode assembly 125preferably conforms to the shape of the nerve, providing a lowstimulation threshold by allowing a large stimulation contact area withthe nerve. Structurally, the electrode assembly 125 comprises twoelectrode ribbons (not shown), of a conductive material such asplatinum, iridium, platinum-iridium alloys, and/or oxides of theforegoing. The electrode ribbons are individually bonded to an insidesurface of an elastomeric body portion of the two spiral electrodes125-1 and 125-2 (FIG. 1C), which may comprise two spiral loops of athree-loop helical assembly. The lead assembly 122 may comprise twodistinct lead wires or a coaxial cable whose two conductive elements arerespectively coupled to one of the conductive electrode ribbons. Onesuitable method of coupling the lead wires or cable to the electrodes125-1, 125-2 comprises a spacer assembly such as that disclosed in U.S.Pat. No. 5,531,778, although other known coupling techniques may beused.

The elastomeric body portion of each loop is preferably composed ofsilicone rubber, and the third loop 128 (which typically has noelectrode) acts as the anchoring tether for the electrode assembly 125.

The electrical pulse generator 110 may be programmed with an externalcomputer 150 using programming software of the type copyrighted by theassignee of the instant application with the Register of Copyrights,Library of Congress, or other suitable software based on the descriptionherein, and a programming wand 155 to facilitate radio frequency (RF)communication between the computer 150 (FIG. 1A) and the pulse generator110. The wand 155 and software permit non-invasive communication withthe generator 110 after the latter is implanted. The wand 155 ispreferably powered by internal batteries, and provided with a “power on”light to indicate sufficient power for communication. Another indicatorlight may be provided to show that data transmission is occurringbetween the wand and the generator.

A variety of stimulation therapies may be provided in implantablemedical systems 100 of the present invention. Different types of nervefibers (e.g., A, B, and C fibers being different fibers targeted forstimulation) respond differently to stimulation from electrical signals.More specifically, the different types of nerve fibers have differentconduction velocities and stimulation thresholds and, therefore, differin their responsiveness to stimulation. Certain pulses of an electricalstimulation signal, for example, may be below the stimulation thresholdfor a particular fiber and, therefore, may generate no action potentialin the fiber. Thus, smaller or narrower pulses may be used to avoidstimulation of certain nerve fibers (such as C fibers) and target othernerve fibers (such as A and/or B fibers, which generally have lowerstimulation thresholds and higher conduction velocities than C fibers).Additionally, techniques such as pre-polarization may be employedwherein particular nerve regions may be polarized before a more robuststimulation is delivered, which may better accommodate particularelectrode materials. Furthermore, opposing polarity phases separated bya zero current phase may be used to excite particular axons or postponenerve fatigue during long term stimulation.

As used herein, the terms “stimulating” and “stimulator” may generallyrefer to delivery of a signal, stimulus, or impulse to neural tissue foraffecting neuronal activity of a neural tissue (e.g., a volume of neuraltissue in the brain or a nerve). The effect of such stimulation onneuronal activity is termed “modulation”; however, for simplicity, theterms “stimulating” and “modulating”, and variants thereof, aresometimes used interchangeably herein. The effect of delivery of thestimulation signal to the neural tissue may be excitatory or inhibitoryand may potentiate acute and/or long-term changes in neuronal activity.For example, the effect of “stimulating” or “modulating” a neural tissuemay comprise on one more of the following effects: (a) changes in neuraltissue to initiate an action potential (bi-directional oruni-directional); (b) inhibition of conduction of action potentials(endogenous or externally stimulated) or blocking the conduction ofaction potentials (hyperpolarizing or collision blocking), (c) affectingchanges in neurotransmitter/neuromodulator release or uptake, and (d)changes in neuro-plasticity or neurogenesis of brain tissue. Applying anelectrical signal to an autonomic nerve may comprise generating aresponse that includes an afferent action potential, an efferent actionpotential, an afferent hyperpolarization, an efferent hyperpolarization,an afferent sub-threshold depolarization, and/or an efferentsub-threshold depolarization.

In some embodiments, the IMD 200 may perform “background” stimulationaccording to a preprogrammed normal operation mode. The backgroundstimulation may refer to a second electrical signal that is deliveredduring a second time period, wherein a normal stimulation mode isimplemented in a first time period. Embodiments of the present inventionmay be employed to provide a second electrical signal at a relativelylow level, e.g., at a level that is substantially imperceptible to apatient, during a secondary period that may include a portion of theoff-time of the first signal. A second electrical signal provided duringan off-time of the first signal may be referred to hereinafter as“background” stimulation or modulation. For example, an IMD 200 mayapply a second electrical signal having a reduced frequency, current, orpulse width relative to the first electrical signal during off-time ofthe first period, in addition to the first electrical signal appliedduring a primary period. Also, an IMD 200 may apply a third electricalsignal having an increased frequency, current, or pulse width relativeto the first electrical signal during off-time of the first period.Without being bound by theory, applying a background electrical signalmay allow the first electrical signal to be reduced to a levelsufficient to reduce one or more side effects without reducingtherapeutic efficacy.

In some embodiments of the present invention, the first and second timeperiods at least partially overlap, and a second electrical stimulationsignal may be applied during at least a portion of the first timeperiod. In a more particular embodiment, the second time period onlypartially overlaps the first, and the second electrical stimulationsignal is applied during a portion of the first time period andcontinues during a period in which the first signal is not applied. Thistype of stimulation is referred to hereinafter as “overlaid” stimulationor modulation. Overlaid and/or background stimulation embodiments of theinvention may increase efficacy of a stimulation therapy, reduce sideeffects, and/or increase tolerability of the first signal to higherlevels of stimulation.

Embodiments of the present invention provide for patient-initiatedelectrical signal therapy based upon one or more external inputsreceived by the IMD 200. For example, the IMD 200 may receive variousinputs that could prompt a temporary interruption or deviation fromnormal stimulation operation. For example, a magnet may be placedproximate to the IMD 200, which may be an indication that the patient ora physician desires to alter the normal operation of the IMD 200. Theamount of time that the magnet is detected may determine the type ofdeviation from the normal operation that will occur. Various devices,e.g., a Reed Switch, a Hall Effect sensor, etc., may be employed todetect a magnetic field in order to react to a magnet being placedproximate to the IMD 200. As another example, a tap sensor may beemployed to detect a tap applied to the skin over the IMD 200. As athird example, an RF sensor may be employed to detect a radio frequencysignal generated proximate to the IMD 200.

Further, an external input received by the IMD 200 may be used totemporarily alter the normal operation of the IMD 200. For example, thepatient may desire to temporarily stop any stimulation activity. Aninput from the patient (e.g., a magnetic input) may be used to suspendstimulation activity. In one embodiment, an input from the patient mayprompt the IMD 200 to enter into reduced stimulation mode, wherein abackground signal that does not cause certain stimulation side-effects,may be implemented. The amount of time to employ the alternativestimulation mode, as well as the type of alternative stimulation mode,may be pre-programmed into the IMD 200, and may be selected from aplurality of pre-programmed alternative stimulation modes.

Alternatively or in addition, an input from the patient may prompt theIMD 200 to perform a patient-initiated electrical signal therapyregardless of whether such therapy is indicated by normal operation ofthe IMD 200. However, depending on the patient, his medical condition,and other considerations, it may be desirable that patient-initiatedelectrical signal therapy be limited in one or more aspects, as will bediscussed in more detail below. For example, for some patients, theremay be a limitation as to the number of patient-initiated electricalsignal therapy operations that may be provided during the alternativestimulation mode.

Turning now to FIG. 2A, a block diagram depiction of an implantablemedical device, in accordance with one illustrative embodiment of thepresent invention is illustrated. The IMD 200 may be used forstimulation to treat various disorders, including without limitationepilepsy, neuropsychiatric disorders (including but not limited todepression), eating disorders/obesity, traumatic brain injury/coma,addiction disorders, dementia, sleep disorders, pain, migraine,endocrine/pancreatic disorders (including but not limited to diabetes),motility disorders, hypertension, congestive heart failure/cardiaccapillary growth, hearing disorders, angina, syncope, vocal corddisorders, thyroid disorders, pulmonary disorders, and reproductiveendocrine disorders (including fertility). The IMD 200 may be coupled tovarious leads, e.g., 122 (FIGS. 1A, 1C). Stimulation signals used fortherapy may be transmitted from the IMD 200 to target areas of thepatient's body, specifically to various electrodes associated with theleads 122. Stimulation signals from the IMD 200 may be transmitted viathe leads 122 to stimulation electrodes (electrodes that apply thetherapeutic electrical signal to the target tissue) associated with theelectrode assembly 125 (FIG. 1A). Further, signals from sensorelectrodes (electrodes that are used to sense one or more bodyparameters such as temperature, heart rate, brain activity, etc.) mayalso traverse the leads back to the IMD 200.

The IMD 200 may comprise a controller 210 capable of controlling variousaspects of the operation of the IMD 200. The controller 210 is capableof receiving internal data and/or external data and generating anddelivering a stimulation signal to target tissues of the patient's body.For example, the controller 210 may receive manual instructions from anoperator externally, or may perform stimulation based on internalcalculations and programming. The controller 210 is capable of affectingsubstantially all functions of the IMD 200.

The controller 210 may comprise various components, such as a processor215, a memory 217, etc. The processor 215 may comprise one or more microcontrollers, micro processors, etc., that are capable of executing avariety of software components. The memory 217 may comprise variousmemory portions, where a number of types of data (e.g., internal data,external data instructions, software codes, status data, diagnosticdata, etc.) may be stored. The memory 217 may store various tables orother database content that could be used by the IMD 200 to implementthe override of normal operations. The memory 217 may comprise randomaccess memory (RAM) dynamic random access memory (DRAM), electricallyerasable programmable read-only memory (EEPROM), flash memory, etc.

The IMD 200 may also comprise a stimulation unit 220. The stimulationunit 220 is capable of generating and delivering a variety of electricalsignal therapy signals to one or more electrodes via leads. Thestimulation unit 220 is capable of delivering either a programmed,primary mode electrical signal or a secondary mode, patient-initiatedelectrical signal to the leads 122 coupled to the IMD 200. The secondarymode, patient initiated signal may be programmed or may determinedaccording to an algorithm in response to a determination of whether athreshold or limit for the electrical signal is exceeded or notexceeded. The electrical signal may be delivered to the leads 122 by thestimulation unit 220 based upon instructions from the controller 210.The stimulation unit 220 may comprise various types of circuitry, suchas stimulation signal generators, impedance control circuitry to controlthe impedance “seen” by the leads, and other circuitry that receivesinstructions relating to the type of stimulation to be performed. Thepatient-initiated electrical signal therapy can be limited as will bedescribed below.

The IMD 200 may also comprise a patient-initiated stimulation controller280. The patient-initiated stimulation controller 280 is capable ofimplementing alternative stimulation modes, such as a patient-initiatedelectrical signal mode, in response to patient input. Thepatient-initiated stimulation controller 280 is shown in more detail inFIG. 2B. A patient input interface 282 detects input from the patient,such as that received from the magnetic field detection unit 290 (FIG.2A), and communicates the detected input to an alternative stimulationmode controller 284. The alternative stimulation mode controller 284controls alternative stimulation, such as a patient-initiated electricalsignal alone or in combination with background stimulation, by takingthe input from the patient input interface 282 and communicating with analternative stimulation selection module 286. The alternativestimulation selection module 286 selects which (if multiple)preprogrammed alternative stimulation modes is to be implemented. Thepreprogrammed modes may be stored within and retrieved from the memory217. Once an alternative stimulation mode is selected by the alternativestimulation selection module 286, it communicates with alternativestimulation mode controller 284, which then implements the alternativestimulation mode. The patient-initiated stimulation controller 280 cancommunicate with the stimulation unit 220 (FIG. 2A) to authorizedelivery of a patient-initiated electrical signal via the leads 122 tothe electrodes 125 and thence to the cranial nerve 127.

In limiting patient-initiated electrical signal therapy provided by theIMD 200, at least one electrical signal therapy limit is specified. Theat least one limit may be selected from the group consisting of amaximum number of patient-initiated signals to provide a therapeuticelectrical signal per a time period, a maximum dose of the therapeuticelectrical signal per a time period, a maximum duration of thetherapeutic electrical signal per a time period, a maximum rate ofchange of the number of patient-initiated signals to provide atherapeutic electrical signal per a time period, a maximum rate ofchange of the dose of the therapeutic electrical signal per a timeperiod, and a maximum rate of change of the duration of the electricalsignal therapy per a time period. In some embodiments, multipleelectrical signal therapy limits may be provided, for example a firstlimit may comprise 5 patient-initiated signals to provide a therapeuticelectrical signal in 24 hours, and a second limit may comprise 8patient-initiated signals to provide a therapeutic electrical signal in48 hours. The at least one electrical signal therapy limit can be storedin memory 217.

Specification of the at least one electrical signal therapy limit can beperformed prior to implantation of the IMD 200, such as during themanufacturing process or by the implanting physician, either to thephysician's default signal therapy limit or to a limit set afterconsideration of the patient's particular medical condition, among otherpossible considerations. Alternatively or in addition, specification ofthe at least one electrical signal therapy limit can be performed afterimplantation, either to the physician's default limit or to a limit setafter consideration of the patient's particular medical condition, histolerance of the IMD 200, and the efficacy of the IMD 200, among otherpossible considerations.

Each of the electrical signal therapy limits listed above can beconsidered over a time period. Any time period can be considered anddefined programmably. In one embodiment, at least one said time periodbegins at implantation of the device. This time period can continueindefinitely, i.e., the time period may comprise the entire operationallife of the unit.

In another embodiment, the time period has a duration of from about 10sec to about 720 hr, such as from about 1 min to about 24 hr, moreparticularly from about 30 min to about 6 hr. The time period can becontinuous, that is, comprising a moving time period representing alength of time ending at the present moment and beginning at a timepointequal to the defined time period duration before the present moment. Forexample, an electrical signal limit may comprise a number ofpatient-initiated signals to provide a therapeutic electrical signal inthe previous 24 hours from the present moment. In such embodiments, thesystem may also define a sampling interval, i.e., may recalculate themoving time period at intervals of from 1 second to one hour, or othertime periods such as every 3 hours, every day, or even longer. Differentsampling intervals may be used depending upon the time period duration,for example a moving time period of 24 hours need not be updated morefrequently than once per hour, as more frequent updating may impose acalculational burden on the IMD that far exceeds any therapeuticbenefit. Alternatively, the time period can be externally synchronized,that is, representing a length of time beginning at a particular pointin time (such as a particular time of the clock or a particular timeafter implantation of the IMD 200) and ending at a point in time equalto the time period duration after the beginning of the time period.

The time period can occur once, such as if the time period is the entireoperational life of the unit, or it can be repeated on a regular orirregular schedule. For example, the time period can be scheduled torepeat at particular hours of the day. In another embodiment, the timeperiod can be scheduled to commence no earlier than a specified lengthof time after an immediately prior time period ended.

Multiple time periods, such as two or more time periods, can beconsidered, wherein the multiple time periods may be consecutive orpartially or wholly overlapping. Reference herein to such embodimentsmay use the terms “first time period,” “second time period,” etc.

In one embodiment, the electrical signal therapy limit is a maximumnumber of patient-initiated signals to provide a therapeutic electricalsignal per a time period. The number of patient-initiated signals toprovide a therapeutic electrical signal can be calculated byincrementing a counter on each patient-initiated signal (magnet swipe,tap, RF communication, or the like) during the time period.

In one embodiment, the electrical signal therapy limit is a maximum doseof neurostimulation charge per a time period. The dose can be calculatedby summing the products of the amplitudes and pulse widths of eachcurrent pulse during the time period. The maximum dose can be consideredfor patient-initiated electrical signal therapy only or for bothpatient-initiated and preprogrammed electrical signal therapy.

In one embodiment, the electrical signal therapy limit is a maximumduration of neurostimulation per a time period. The duration can becalculated by summing the durations of each current pulse during thetime period. The maximum duration can be considered forpatient-initiated electrical signal therapy only or for bothpatient-initiated and preprogrammed electrical signal therapy.

In one embodiment, the electrical signal therapy limit is a maximum rateof change of the number of neurostimulation bursts per a time period.The rate of change is defined as the absolute magnitude of the number ofbursts in a first subperiod minus the number of bursts in a secondsubperiod.

In one embodiment, the electrical signal therapy limit is a maximum rateof change of the dose of neurostimulation charge per a time period. Therate of change is defined as the absolute magnitude of the charge dosein a first subperiod minus the charge dose in a second subperiod. Themaximum rate of change can be considered for patient-initiatedelectrical signal therapy only or for both patient-initiated andpreprogrammed electrical signal therapy.

In one embodiment, the electrical signal therapy limit is a maximum rateof change of the duration of neurostimulation per a time period. Therate of change is defined as the absolute magnitude of the summeddurations of current pulses in a first subperiod minus the summeddurations of current pulses in a second subperiod. The maximum rate ofchange can be considered for patient-initiated electrical signal therapyonly or for both patient-initiated and preprogrammed electrical signaltherapy.

In one embodiment, a first time period has a duration of about 2 hr anda second time period has a duration of about 4 hr or about 6 hr, whereinthe maximum number of patient-initiated signals to provide a therapeuticelectrical signal during the second time period is zero.

In one embodiment, a first time period has a duration of about 2 hr anda second time period has a duration of at least about 4 hr or about 6hr, wherein a first time period begins at the first patient initiationof neurostimulation after the minimum duration of the second time periodhas occurred and wherein the maximum number of patient-initiated signalsto provide a therapeutic electrical signal during the second time periodis zero.

Returning to FIG. 2A, at least one of a presence of a magnetic field, atap input, or a radio frequency (RF) input can be detected by apparatusknown in the art, such as those discussed above. The apparatus, forexample the magnetic field detection unit 290, or the IMD controller 215may determine a characteristic of said magnetic field, tap input, or RFinput, such as determining at least one of a duration of said magneticfield, a magnitude of said magnetic field, or a number of tap inputsreceived, among other characteristics.

Based on the at least one electrical signal therapy limit specifiedabove and stored in memory 217, and the receipt of said at least one ofsaid presence of said magnetic field, said tap input, or said RF input,such as a magnetic field detected by magnetic field detection unit 290,whether or not said electrical signal therapy limit is exceeded by saidstep of detecting a patient-initiated signal is determined. Thedetermination can involve a comparison of the calculated number ofpatient-initiated signals, the total dose, the total duration, or therate of change of any of the foregoing with the electrical signaltherapy limit in view of the patient-initiated signal, characteristicsof the received input, and the various modes of electrical signaltherapy with which the unit may be preprogrammed.

In response to said step of determining whether or not said limit isexceeded, an action is performed selected from the group consisting ofproviding a first electrical signal therapy to said cranial nerve,providing a second, reduced electrical signal therapy to said cranialnerve, providing a third, enhanced electrical signal therapy to saidcranial nerve, inhibiting an electrical signal therapy to said cranialnerve, providing a background electrical signal to said cranial nerve,and inhibiting a background electrical signal to said cranial nerve.

In one embodiment, if patient-initiated electrical signal is notpermitted (e.g., the maximum number of patient-initiated signals, thetotal dose, the total duration during the currently elapsing time periodis zero, or such limit is greater than zero but has already been reachedduring the currently elapsing time period), then no electrical signaltherapy is performed in response to the received input. In anotherembodiment, if patient-initiated electrical signal is permitted duringthe currently elapsing time period, then the electrical signal therapymay follow the first mode of electrical signal therapy, a second modeelectrical signal therapy reduced in one or more electrical signalstimulation parameters relative to the first mode (e.g., a mode having alower pulse amplitude, pulse frequency, burst duration, interburstinterval, or two or more thereof, among other electrical signalcharacteristics) may be applied to the cranial nerve 127, or a thirdmode electrical signal therapy may be applied that is increased in oneor more electrical signal stimulation parameters relative to the firstmode (e.g., a mode having a greater pulse amplitude, pulse frequency,burst duration, interburst interval, or two or more thereof, among otherelectrical signal characteristics). The mode of electrical stimulationcan be chosen or modified by the processor 215 and communicated to thestimulation unit 220.

In one embodiment, at least one neurostimulation parameter can bedetermined by the controller 215 based upon whether or not theelectrical signal therapy limit is exceeded or is not exceeded. If thelimit is not exceeded, a first electrical signal therapy may be providedto the patient. Providing the first electrical signal therapy maycomprise providing a pulsed electrical signal defined by at least oneparameter selected from the group consisting of a first currentamplitude, a first pulse width, a first frequency, a first on-time, afirst off-time, a first number of pulses per burst, a first interburstperiod, and a first interpulse interval;

If the electrical signal therapy is exceeded, in one embodiment,electrical signal therapy may be inhibited. This may involve completelyinhibiting patient-initiated therapy for a predetermined time period, oruntil it is subsequently determined that the limit is no longerexceeded. In another embodiment, inhibiting the electrical signaltherapy may comprise providing a second, reduced electrical signaltherapy to the patient, with the reduced electrical signal therapycomprising providing a pulsed electrical signal defined by at least oneparameter selected from the group consisting of a second currentamplitude less than said first current amplitude, a second pulse widthless than said first pulse width, a second frequency less than saidfirst frequency, a second on-time less than said first on-time, a secondoff-time greater than said first off-time, a second number of pulses perburst less than said first number of pulses per burst, a secondinterburst period greater than said first interburst period, and asecond interpulse interval greater than said first interpulse interval.

In yet an another embodiment, the action in response to the step ofdetermining whether or not the electrical signal therapy limit isexceeded may comprise providing a third, enhanced electrical signaltherapy that, in turn, comprises a pulsed electrical signal defined byat least one parameter selected from the group consisting of a thirdcurrent amplitude greater than said first current amplitude, a thirdpulse width greater than said first pulse width, a third frequencygreater than said first frequency, a third on-time greater than saidfirst on-time, a third off-time less than said first off-time, a thirdnumber of pulses per burst greater than said first number of pulses perburst, a third interburst period less than said first interburst period,and a third interpulse interval less than said first interpulseinterval.

Algorithms for determining the at least one neurostimulation parameterdiscussed above can be stored in memory 217 as a function of the atleast one electrical signal therapy limit, the magnitude by which thelimit is (or is not) exceeded, or other properties.

The IMD 200 may also comprise a power supply 230. The power supply 230may comprise a battery, voltage regulators, capacitors, etc., to providepower for the operation of the IMD 200, including delivering thestimulation signal. The power supply 230 comprises a power-sourcebattery that in some embodiments may be rechargeable. In otherembodiments, a non-rechargeable battery may be used. The power supply230 provides power for the operation of the IMD 200, includingelectronic operations and the stimulation function. The power supply230, may comprise a lithium/thionyl chloride cell or a lithium/carbonmonofluoride cell. Other battery types known in the art of implantablemedical devices may also be used.

The IMD 200 also comprises a communication unit 260 capable offacilitating communications between the IMD 200 and various devices. Inparticular, the communication unit 260 is capable of providingtransmission and reception of electronic signals to and from an externalunit 270. The external unit 270 may be a device that is capable ofprogramming various modules and stimulation parameters of the IMD 200.In one embodiment, the external unit 270 comprises a computer systemthat is capable of executing a data-acquisition program. The externalunit 270 may be controlled by a healthcare provider, such as aphysician, at a base station in, for example, a doctor's office. Theexternal unit 270 may be a computer, preferably a handheld computer orPDA, but may alternatively comprise any other device that is capable ofelectronic communications and programming. The external unit 270 maydownload various parameters and program software into the IMD 200 forprogramming the operation of the implantable device. The external unit270 may also receive and upload various status conditions and other datafrom the IMD 200. The communication unit 260 may be hardware, software,firmware, and/or any combination thereof. Communications between theexternal unit 270 and the communication unit 260 may occur via awireless or other type of communication, illustrated generally by line275 in FIG. 2A.

In one embodiment, the communication unit 260 can transmit a log ofstimulation data to the patient, a physician, or another party.

The IMD 200 is capable of delivering stimulation that can beintermittent, periodic, random, sequential, coded, and/or patterned. Thestimulation signals may comprise an electrical stimulation frequency ofapproximately 0.1 to 2500 Hz. The stimulation signals may comprise apulse width of in the range of approximately 1-2000 micro-seconds. Thestimulation signals may comprise current amplitude in the range ofapproximately 0.1 mA to 10 mA. Stimulation may be delivered througheither the cathode (−) electrode or anode (+) electrode. In oneembodiment, the various blocks illustrated in FIG. 2A may comprisesoftware unit, a firmware unit, a hardware unit, and/or any combinationthereof. The stimulation delivered by the IMD 200 in the absence ofpatient-initiated electrical signal may be referred to herein as “normaloperations” or “normal operating mode.”

The IMD 200 may also comprise a magnetic field detection unit 290. Themagnetic field detection unit 290 is capable of detecting magneticand/or electromagnetic fields of a predetermined magnitude. Whether themagnetic field results from a magnet placed proximate to the IMD 200, orwhether it results from a substantial magnetic field encompassing anarea, the magnetic field detection unit 290 is capable of informing theIMD of the existence of a magnetic field.

The magnetic field detection unit 270 may comprise various sensors, suchas a Reed Switch circuitry, a Hall Effect sensor circuitry, and/or thelike. The magnetic field detection unit 270 may also comprise variousregisters and/or data transceiver circuits that are capable of sendingsignals that are indicative of various magnetic fields, the time periodof such fields, etc. In this manner, the magnetic field detection unit270 is capable of detecting whether the detected magnetic field relatesto an inhibitory input or an excitory input from an external source. Theinhibitory input may refer to an inhibition of, or a deviation from,normal stimulation operation. The excitory input may refer to additionalstimulation or deviation from normal stimulation.

One or more of the blocks illustrated in the block diagram of the IMD200 in FIG. 2A, may comprise hardware units, software units, firmwareunits, or any combination thereof. Additionally, one or more blocksillustrated in FIG. 2A may be combined with other blocks, which mayrepresent circuit hardware units, software algorithms, etc.Additionally, one or more of the circuitry and/or software unitsassociated with the various blocks illustrated in FIG. 2A may becombined into a programmable device, such as a field programmable gatearray, an ASIC device, etc.

Methods of applying alternative stimulation may include applying apatient-initiated electrical signal mode alone or in combination withbackground stimulation. Turning now to FIG. 3, a flowchart depiction ofa method for limiting patient-initiated electrical signal therapy inaccordance with one illustrative embodiment of the present invention isprovided. At least one electrical signal therapy limit is specified(block 410) prior to normal operation, such as primary mode operation,of the IMD 200 (block 420). The normal operation mode calls forpredetermined delivery of stimulation signals. The IMD 200 may thencheck to determine whether a patient-initiated signal to administerpatient-initiated electrical signal therapy has been received (block430). If an input to administer patient-initiated electrical signaltherapy has not been received, normal operation of the IMD and deliveryof stimulation signal is resumed, as indicated in FIG. 3.

However, if it is determined that an input signal promptingadministration of patient-initiated electrical signal therapy has beendetected, the IMD 200 may determine whether the at least one electricalsignal therapy limit has been exceeded (block 440).

Depending on whether the at least one electrical signal therapy limitwas or was not exceeded, the IMD 200 may perform patient-initiatedelectrical signal therapy. Performing may involve one or more of thefollowing:

provide a first electrical signal therapy to said cranial nerve; or,

provide a second, reduced electrical signal therapy to said cranialnerve; or,

provide a third, enhanced electrical signal therapy to said cranialnerve; or,

inhibit an electrical signal therapy to said cranial nerve; or,

provide a background electrical signal to said cranial nerve; or,

inhibit a background electrical signal to said cranial nerve.

The word “or” is used in the inclusive sense.

After performing patient-initiated electrical signal therapy asdescribed above, the IMD 200 returns to normal operation mode (block420).

The particular embodiments disclosed above are illustrative only as theinvention may be modified and practiced in different but equivalentmanners apparent to those skilled in the art having the benefit of theteachings herein. Furthermore, no limitations are intended to thedetails of construction or design herein shown other than as describedin the claims below. It is, therefore, evident that the particularembodiments disclosed above may be altered or modified and all suchvariations are considered within the scope and spirit of the invention.Accordingly, the protection sought herein is as set forth in the claimsbelow.

1. A method of electrical signal therapy provided by an implantablemedical device (IMD) to a cranial nerve of a patient, comprising:specifying an electrical signal parameter threshold; wherein saidelectrical signal parameter is specific to the electrical signaltherapy; and wherein said threshold is selected from the groupconsisting of a maximum number of patient-initiated signals to provide atherapeutic electrical signal per a time period, a maximum dose oftherapeutic electrical signals per a time period, a maximum duration ofthe therapeutic electrical signals per a time period, a maximum rate ofchange of the number of patient-initiated signals to provide atherapeutic electrical signal per a time period, a maximum rate ofchange of the dose of the therapeutic electrical signal per a timeperiod, and a maximum rate of change of the duration of the electricalsignal therapy per a time period, receiving an input from said patientto enter an alternative mode of electrical signal therapy; wherein saidalternative mode of electrical signal therapy comprises altering theelectrical signal parameter of the electrical signal therapy and whereinsaid input from said patient to enter said alternative mode ofelectrical signal therapy also prompts a temporary interruption from anormal stimulation mode of electrical signal therapy provided by theIMD; determining whether to implement said alternative mode ofelectrical signal therapy based on said electrical signal parameterthreshold, and performing said alternative mode of electrical signaltherapy when said electrical signal parameter of said alternative modeof electrical signal therapy is below said threshold, and not performingsaid alternative mode of electrical signal therapy when said electricalsignal parameter of said alternative mode of electrical signal therapyis above said threshold, to inhibit the patient initiated electricalsignal therapy provided by the IMD to the cranial nerve of the patient.2. The method of claim 1, wherein said performing the alternative modeof electrical signal therapy is selected from the group consisting ofproviding a first electrical signal therapy to said cranial nerve,providing a second, reduced electrical signal therapy to said cranialnerve, providing a third, enhanced electrical signal therapy to saidcranial nerve, and providing a background electrical signal to saidcranial nerve.
 3. The method of claim 1, wherein not performing saidalternative mode comprises an action selected from the group consistingof inhibiting an electrical signal therapy to said cranial nerve andinhibiting a background electrical signal to said cranial nerve.
 4. Amethod for limiting patient-initiated electrical signal therapy providedby an implantable medical device (IMD) to a cranial nerve of a patient,comprising: specifying at least one electrical signal therapy limitselected from the group consisting of a maximum number ofpatient-initiated signals to provide a therapeutic electrical signal pera time period, a maximum dose of the therapeutic electrical signal per atime period, a maximum duration of the therapeutic electrical signal pera time period, a maximum rate of change of the number ofpatient-initiated signals to provide a therapeutic electrical signal pera time period, a maximum rate of change of the dose of the therapeuticelectrical signal per a time period, and a maximum rate of change of theduration of the electrical signal therapy per a time period; receiving apatient-initiated signal to begin a patient-initiated therapeuticelectrical signal, wherein the patient-initiated therapeutic signalprompts a temporary interruption from a normal stimulation mode ofelectrical signal therapy; determining whether or not saidpatient-initiated electrical signal therapy limit will be exceeded ifsaid receiving the patient-initiated signal to begin thepatient-initiated electrical signal therapy is implemented; performingan action when said limit is not exceeded, said action selected from thegroup consisting of providing an electrical signal therapy to saidcranial nerve, providing a reduced electrical signal therapy to saidcranial nerve, providing an enhanced electrical signal therapy to saidcranial nerve and providing a background electrical signal to saidcranial nerve; and performing a different action when said limit isexceeded, said different action selected from the group consisting ofinhibiting said patient-initiated electrical signal therapy to saidcranial nerve.
 5. The method of claim 4, further comprising determininga characteristic of said patient-initiated signal, wherein thepatient-initiated signal is a magnetic field, comprising determining atleast one of a duration of said magnetic field and a magnitude of saidmagnetic field, and wherein said characteristic is used in determiningwhether or not said electrical signal therapy limit is exceeded.
 6. Themethod of claim 4, further comprising determining a characteristic ofsaid patient-initiated signal, wherein the patient-initiated signal is atap input, comprising determining a number of tap inputs received, andwherein said characteristic is used in determining whether or not saidelectrical signal therapy limit is exceeded.
 7. The method of claim 4,wherein the at least one electrical signal therapy limit is specifiedfor at least one time period.
 8. The method of claim 7, wherein said atleast one time period has a duration from about 10 sec to about 720 hr.9. The method of claim 7, wherein the at least one electrical signaltherapy limit is specified for a plurality of time periods.
 10. Themethod of claim 4, wherein providing a first electrical signal therapycomprises providing a pulsed electrical signal defined by at least oneparameter selected from the group consisting of a first currentamplitude, a first pulse width, a first frequency, a first on-time, afirst off-time, a first number of pulses per burst, a first interburstperiod, and a first interpulse interval; wherein providing a second,reduced electrical signal therapy comprises providing a pulsedelectrical signal defined by at least one parameter selected from thegroup consisting of a second current amplitude less than said firstcurrent amplitude, a second pulse width less than said first pulsewidth, a second frequency less than said first frequency, a secondon-time less than said first on-time, a second off-time greater thansaid first off-time, a second number of pulses per burst less than saidfirst number of pulses per burst, a second interburst period greaterthan said first interburst period, and a second interpulse intervalgreater than said first interpulse interval; and wherein providing athird, enhanced electrical signal therapy comprises providing a pulsedelectrical signal defined by at least one parameter selected from thegroup consisting of a third current amplitude greater than said firstcurrent amplitude, a third pulse width greater than said first pulsewidth, a third frequency greater than said first frequency, a thirdon-time greater than said first on-time, a third off-time less than saidfirst off-time, a third number of pulses per burst greater than saidfirst number of pulses per burst, a third interburst period less thansaid first interburst period, and a third interpulse interval less thansaid first interpulse interval.
 11. A method for limitingpatient-initiated electrical signal therapy provided by an implantablemedical device (IMD) to a cranial nerve of a patient, comprising:specifying at least one limit on patient-initiated electrical signaltherapy to a the cranial nerve of a the patient; wherein the at leastone limit is selected from the group consisting of a maximum number ofpatient-initiated signals to provide a therapeutic electrical signal pera time period, a maximum dose of the therapeutic electrical signal per atime period, a maximum duration of the therapeutic electrical signal pera time period, a maximum rate of change of the number ofpatient-initiated signals to provide a therapeutic electrical signal pera time period, a maximum rate of change of the dose of the therapeuticelectrical signal per a time period, and a maximum rate of change of theduration of the electrical signal therapy per a time period; receiving apatient-initiated signal to provide an electrical signal therapy to athe cranial nerve, wherein the patient-initiated signal prompts atemporary interruption from a normal stimulation mode of electricalsignal therapy provided by the IMD: determining whether or not said atleast one limit on patient-initiated therapy is exceeded by said step ofreceiving the a patient-initiated signal; providing thepatient-initiated electrical signal therapy to said cranial nerve of thepatient if said at least one limit is not exceeded by said step ofreceiving a the patient-initiated signal; and not providing thepatient-initiated electrical signal therapy to said cranial nerve of thepatient if said at least one limit is exceeded by said step of receivinga the patient-initiated signal, wherein not providing thepatient-initiated electrical signal therapy comprises inhibiting patientinitiated electrical signals to said cranial nerve of the patient. 12.The method of claim 11, wherein receiving said patient-initiated signalcomprises receiving at least one of a tap input or a magnetic input. 13.The method of claim 11, wherein the at least one electrical signaltherapy limit is specified for at least one time period.
 14. The methodof claim 11, wherein said step of providing the electrical signaltherapy if said at least one limit is not exceeded comprises providing apulsed electrical signal defined by at least one parameter selected fromthe group consisting of a current amplitude, a pulse width, a frequency,an on-time, an off-time, a number of pulses per burst, an interburstperiod, and an interpulse interval.
 15. The method of claim 13, whereinsaid time period has a duration from about 10 sec to about 720 hr.